NTSB report: Here’s how to overshoot an airport

The National Transportation Safety Board released today its first fact-finding report on the 77-minute disappearance of Northwest Airlines Flight 188.  It’s 400 pages long and makes no effort to assess blame on how two pilots managed to overshoot the Twin Cities airport.

Blame will come later.

Suffice to say, it does not look good for the Captain Timothy Cheney and First Officer Richard Cole, who apparently were so busy on their laptops digesting new scheduling procedures on the newly merged Delta and Northwest Airlines that they sort of took their eyes off the basic job, which was to safely fly 144 passengers and three flight attendants from San Diego to the Twin Cities on Oct. 21, without passing over Eau Claire. 



There might also be some attention paid to the various communications systems used between ground and pilots, not to mention some fundamental telephone ground-to-ground problems. At one point, while people in Denver, Minneapolis, Sioux Falls and Winnipeg all are wondering what the hell happened to Flight 188, an official in Minneapolis is put on hold by an official in Atlanta.

It’s also clear from the report that the merger of two huge airlines – Northwest and Delta – requires more than slapping a new coat of paint over corporate logos.

But all in all, the report’s a little dry and, of course, riddled with acronyms. There are no big revelations. 

It’s not nearly so entertaining as the jokes that filled the airwaves in the days following the flight.

Remember David Letterman’s Top 10 list about the flight? The top three “pilot excuses” on the Letterman list were: 3, “According to our map, we only missed target by half-an-inch.” 2, “For a change, decided to send luggage to the right city and lose the passengers.” 1, “Thought we saw balloon boy.”

It should be noted the pilots used none of the excuses from Letterman’s list.

‘There’s no excuse’

In fact, Cole notes in his interview with the NTSB folks that “there’s no excuse. . . .I let my guard down. . . .I wish I could explain why.”

They didn’t fall asleep, Cheney said. They didn’t argue.  He added, they did do a good job landing the plane – albeit after a slightly longer flight than scheduled.

We don’t know just what the pilots said to traffic control when radio contact was re-established after the long silence. Recorder transcripts are not included in the report.

But it’s pretty clear the pilots knew that they had committed more than a little “oops” when they finally got back to the business of talking to traffic controllers.

They had to know they were in trouble because traffic control wanted to know if “the cockpit was secure.”

That question was asked on two separate occasions because air officials in both Denver and Minneapolis were discussing whether fighter jets needed to be scrambled to check out what was happening with Flight 188.

The pilots – twice – assured the people in the Twin Cities that the cockpit was secure.

They were asked “what caused the situation?”

The response from either Cheney or Cole: “Cockpit distraction.”

That response was not good enough for flight folks in Denver. They wanted Twin Cities officials to get more information.

So Cheney and Cole were asked for more details.

Ground personnel were told by the pilots that they were in discussion about company policy and that was all they wanted to say.

If those little exchanges weren’t enough to indicate to Cheney and Cole that they were facing some pretty difficult problems, they certainly knew when they finally did land. The two were greeted by a raft of officials and police. They were immediately given a breathalyzer test and a drug test. (They passed both.)

But the two pilots both have had their flying certificates revoked. Both are appealing their revocations

No answer

The report is filled with some very 21st Century moments that presumably will lead to some communications changes.

Go back to that put-on-hold moment. Remember, contact has been lost with an airplane carrying 144 people. Traffic controllers and other pilots are trying to make contact with Flight 188. (According to the report, there were at least 15 efforts to make radio contact. No response.)

 This could be a very dire thing. Have terrorists returned? Is the plane falling apart? What’s going on?

In the midst of this, a Minneapolis official tries to make a phone connection with the airlines’ the Northwest-Delta dispatchers, who now are all located in Atlanta.

Number is called.

There’s a recorded message: “You have the wrong number, dial. . . .”

The new number is called. No answer.

The new number is called again. No answer.

The new number is called again. The Minneapolis caller is put on hold – for several minutes before finally making the connection.

It’s a good bet the safety board will suggest a few improvements in communications.

The merger does get considerable mention in the report because it was the merger — and the changes it has created — that was more on the minds of the pilots than those 144 people they were hauling.

The merger came on April 8, 2008. By the time of wayward Flight 188, employees of the new company were in Phase 4 of the merging process, the longest, most sticky aspect of the merger.

New policies were much on the mind of Cheney as, jacketless and hatless (it was warm in San Diego), he boarded the plane. Cheney, 53, had flown for Northwest since 1985 and now was trying to get used to the new bidding process used for pilots’ working schedules.

Once the plane was at cruising altitude and on automatic pilot, he’d taken a lavatory break and came back and had an airlines’ meal – meat and potatoes.

Cheney said he asked Cole if he “liked his bids.”

Cole responded that he wasn’t happy with the jobs he’d received.

Cheney pulled out his laptop, noting that schedule changes were all electronic now and required a laptop.

After four or five minutes of conversation, Cole pulled out his laptop, too.

(Use of the laptops appears to be a violation of the airlines’ procedures.)

Cheney said he put away his laptop in “four or five minutes” but that Cole kept his out and the two continued their conversation. Cheney said he was taking notes. He could hear “chatter but never a radio call” and that he “no one called us” that he could recall.

‘In shock’

The conversation went on and on, only ending, Cheney said, when a flight attendant called and asked when they would be landing.

He surveyed the situation, noting on a display screen that the Duluth airport was to the left and Eau Claire was to “the 2 o’clock position” — and no estimated arrival time was showing on the display panel.

He said that he when he realized what had happened, he turned to Cole and said, “We just flew over the Minneapolis airport.”

He said he was “in shock.” But his first thought was to get the plane on the ground and explain what happened later.

How, how, how could he have missed all the messages?

Cheney could only say that when he flew B-757s, there was a chime that would ring when a dispatch would arrive.

“I sure wish we had one of those [on the Airbus A320 he was flying],” he told safety board investigators. “If we had one of those I wouldn’t be sitting here today.”

There’s more to come, of course, including blame.

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Comments (4)

  1. Submitted by Paul Brandon on 12/17/2009 - 10:18 am.

    I suppose the good news is that the incident shows that planes can really fly themselves, and that there’s enough redundancy in the system so that a flight can survive major major flight crew misbehavior.
    There’s a relationship here to the credit given to Sully Sullenberger’s plan for the safe landing in the Hudson.

  2. Submitted by James Hamilton on 12/17/2009 - 06:28 pm.

    There simply is no excuse for the pilots’ actions. They should never be permitted to fly a commercial aircraft again.

  3. Submitted by Erik Granse on 12/17/2009 - 08:58 pm.

    There’s a very good writeup on the whole situation over at Salon: http://www.salon.com/tech/col/smith/2009/12/10/askthepilot344/index.html

    Essentially, lots of little mistakes were made by a large number of people–not just the pilots.

    No one was ever in danger, and this whole thing has been blown way out of proportion. The claim that these pilots should lose their livelihood over this incident is absurd.

  4. Submitted by Greg Boone on 12/21/2009 - 02:03 am.

    They shouldn’t lose their livelihood, but they shouldn’t be allowed to fly a commercial airliner if they can be so distracted by new company policies that they completely stop paying attention to where they are on the map. Had the flight attendant not asked when they were going to land, who knows how far they would have gotten before realizing they missed the airport? There’s no excuse for that kind of incompetence.

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